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Objective: To assess whether there is a difference in the behavior of fetuses of pregnant women with diabetes under treatment with insulin, compared to fetuses of pregnant women without diabetes., Materials and Methods: Kurjak's antenatal neurodevelopmental test (KANET) - a method that, by application of four-dimensional (4D) ultrasound, assesses fetal behavior in a similar way that neonatologists perform a neurological assessment in newborns - was applied from 28 to 38 weeks of gestation to 40 pregnancies with pre-existing diabetes mellitus or gestational diabetes mellitus (GDM) requiring insulin (diabetic group) and to 40 non-diabetic cases, with otherwise low-risk pregnancies (non-diabetic group)., Results: There were no statistically significant differences regarding maternal age (30.5±5.1 years for diabetic group vs. 29.8±6.2 years for non-diabetic group) and gestational age (32±1.6 weeks for the diabetic group compared to 33±1.2 weeks for the non-diabetic group). After analysis of the results obtained from application of KANET to each group, results of KANET had higher scores in the non-diabetic group., Conclusion: It appears that there are differences in the fetal behavior between diabetic and non-diabetic fetuses, and also the specific parameters - movements that were different between the two groups were identified.

Objective: To assess the relationship between the cerebroplacental ratio (CPR) and intrapartum and perinatal outcomes in pregnancies complicated by gestational diabetes mellitus (GDM)., Methods: This was a retrospective cohort study of women with a non-anomalous singleton pregnancy diagnosed with GDM who delivered at Mater Mothers' Hospital between 2007 and 2015. CPR was measured in 1089 cases between 34 + 0 and 36 + 6 weeks' gestation. CPR values were compared between groups categorized according to GDM treatment (by diet, oral hypoglycemic agent (OHA) or insulin). The association between CPR and intrapartum and perinatal outcomes was evaluated., Results: No difference in CPR was observed between treatment groups. Fetuses with CPR < 10 th centile were significantly more likely to have adverse composite perinatal outcome (odds ratio (OR) = 2.93 (95% CI, 1.95-4.40)), preterm delivery and low birth weight than fetuses with CPR ≥ 10 th centile (all P < 0.001). These associations were present regardless of the type of GDM treatment. Fetuses of women with insulin-controlled GDM had poorer neonatal outcomes than did fetuses of women treated with OHA or dietary control alone. The risk of adverse outcome was significantly increased in the insulin-treated group (OR = 1.75 (95% CI, 1.34-2.28); P < 0.001), which also had higher rates of preterm delivery and higher birth weight., Conclusion: Regardless of the type of treatment, a low CPR is associated with poorer neonatal outcome in women with GDM. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: This study aimed to assess the relationship between the cerebro-placental ratio (CPR) and intrapartum and perinatal outcomes in pregnancies complicated by pre-existing insulin dependent diabetes (pT1DM) mellitus, pre-existing non-insulin dependent diabetes mellitus (pT2DM) and gestational diabetes mellitus (GDM)., Study Design: This was a retrospective cohort study of 1281 women with diabetes mellitus birthing at the Mater Mothers' Hospital in Brisbane between 2007 and 2015. The CPR in non-anomalous singleton fetuses was measured between 34+0 and 36+6 weeks gestation and compared between types of DM treatment groups and correlated with intrapartum and perinatal outcomes., Results: Of the study cohort, 9.7% (124/1281) had pT1DM, 5.3% (68/1281) had pT2DM and 85.0% (1089/1281) had GDM. Of women with pT2DM and GDM, 61.8% (42/68) and 28.9% (315/1089) respectively, required insulin during pregnancy. Women with pT1DM had an increased odds of having a CPR <5th centile (OR 3.73, 95%CI: 1.90-6.96, p=0.0001) or a CPR <10th centile (OR 3.01, 95% CI: 1.80-4.91, p<0.0001) respectively. The odds of a UA PI >90th centile (OR 2.69, 95% CI: 1.60-4.39, p=0.0001) was higher in the pT1DM cohort. There was however no significant difference in the mean MCA PI between the three groups. Stratification by CPR centiles (<10th centile vs. ≥10th centile) demonstrated a lower birth weight in the CPR <10th centile cohort for all DM categories. The proportion of neonates with birth weights <10th centile were higher in the CPR <10th centile cohort with the GDM cohort having an odds ratio of 8.28 (95% CI 4.22-16.13, p<0.0001) of this complication. The CPR <10th centile cohort also had a greater proportion of adverse composite neonatal outcome regardless of type of DM., Conclusions: Regardless of the type of DM, a low CPR was associated with poorer neonatal outcomes. Women with pT1DM also had the highest mean UA PI and lowest mean CPR despite no difference in the mean MCA PI between the three groups., (Copyright © 2017 Elsevier B.V. All rights reserved.)

The objective of the study was to assess the temporal changes in vascular function during pregnancy in healthy women and in those with gestational diabetes mellitus (GDM). Assessment of vascular function was done at three time points, 11-13 +6 weeks +days , 20-22 +6 weeks +days and 30-32 +6 weeks +days , by flow-mediated dilatation (FMD), augmentation index (AIx) and carotid-radial pulse wave velocity (crPWV) in women ( n=100) with singleton pregnancies. Out of the 100 women, 20 developed GDM, who were compared with 20 healthy, age-matched pregnant women in a nested case-control design. Women with GDM had lower FMD% in the third compared to the first trimester (6.77 (4.36-9.96) vs 9.76 (6.66-16.61)%; p = 0.026); however, FMD% was similar on inter-group comparison between GDM and healthy pregnancies. AIx was significantly higher in GDM than healthy pregnancies at both first (15.35 ± 10.57 vs 6.45 ± 9.81%; p<0.05) and second trimesters (15.00 ± 8.44 vs 2.50 ± 9.01%; p<0.05). A higher AIx in early pregnancy differentiates women with GDM from those with healthy pregnancies.

Purpose: The left ventricle (LV) undergoes physiologic remodeling in adaptation to the hemodynamic changes that occur in pregnancy. Speckle tracking echocardiography (STE) is a novel and reliable tool to evaluate subtle myocardial alterations that have been utilized to assess myocardial changes in patients with diabetes mellitus (DM) but not in patients with gestational DM (GDM). We seek to evaluate changes in LV function using STE in patients with GDM compared with women with normal pregnancy., Methods: This was a single-center retrospective cohort study. A total of 312 pregnant patients that underwent transthoracic echocardiogram (TTE) between 2009 and 2014 were screened. After excluding patients with comorbidities or insufficient data, 90 women were included. TTE from the second and third trimester for each patient were then reviewed, and STE analysis was performed., Results: Of the 90 subjects, 72 had normal pregnancies and 18 developed GDM. There was no difference in LV end-diastolic diameter (4.73 ± 0.40 versus 4.60 ± 0.56, p = 0.25), LV end-systolic diameter (3.12 ± 0.35 versus 2.91 ± 0.61, p = 0.152), or ejection fraction (62.26 ± 4.12 versus 63.50 ± 5.24, p = 0.314) between the two groups. Global longitudinal strain was lower (-19.8 ± 3.34 versus -17.2 ± 2.18, p < 0.001) in patients with GDM, while time-to-peak strain was greater (0.43 ± 0.05 versus 0.50 ± 0.06, p < 0.001). Circumferential and radial strains were preserved in both groups., Conclusions: Although conventional TTE variables show preserved LV size and function, LV longitudinal strain suggests subclinical myocardial dysfunction in patients with GDM. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:20-27, 2017., (© 2016 Wiley Periodicals, Inc.)

Our aim was to evaluate the association between gestational diabetes mellitus and sonographically measured fetal epicardial fat thickness between 24-28 weeks' gestation. This was a cross-sectional study that included 40 pregnancies with gestational diabetes mellitus, matched with 40 normal pregnancies with similar maternal age, body-mass index, gestational age, fetal gender, and fetal abdominal circumference on ultrasound. Fetal epicardial fat thickness was measured and recorded during ultrasonography at 24-28 weeks of gestation. Maternal evaluation included measurement of maternal epicardial fat thickness, using echocardiography. Fetal and maternal epicardial fat thickness values were compared across the groups. Ultrasound views of fetal epicardial fat thickness were evaluated independently by 3 perinatology fellows to determine inter- and intra-observer variability. Partial and intraclass correlation analyses were used. Fetal and maternal epicardial fat thickness measurements were moderately correlated (r=0.63). Mean fetal and maternal epicardial fat thickness values were higher in gestational diabetes mellitus pregnancies (p=0.004 and p<0.0001, respectively) compared to controls. Fetal epicardial fat thickness was positively correlated (r=0.43) with postchallenge 2-h glucose values. Inter- and intra-observer agreement was high, demonstrated by strong correlations (r=0.99 and r=0.99, respectively) across fetal epicardial fat thickness measurements of the examiners. Fetuses from gestational diabetes mellitus pregnancies have significantly higher fetal and maternal epicardial fat thickness values compared to nongestational diabetes mellitus pregnancies. Fetal epicardial fat thickness obtained during second trimester fetal anatomy ultrasound may potentially be a reliable indicator for gestational diabetes mellitus. However, clinical validation studies are needed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The purpose of this study was to investigate the clinical value of velocity vector imaging in the assessment of regional left ventricular longitudinal function in fetuses with gestational diabetes mellitus., Methods: Digital dynamic four-chamber views of 98 fetuses with gestational diabetes mellitus and 135 normal fetuses were collected and analyzed using velocity vector imaging. The regional tissue velocity, strain, and strain rate of the interventricular septum and left lateral wall were separately measured in systole and diastole., Results: A total of 207 of 233 cases were analyzed successfully. Vs (systolic velocity) and Vd (diastolic velocity) were age-dependent and gradually decreased from the basal segment to the apical segment in the left ventricle (P < 0.05). The Vs after 32(+0) weeks, Vd after 28(+0) weeks, and S (strain), SRs (systolic strain rate), and SRd (diastolic strain rate) after 24(+0) weeks in the left ventricle of fetuses with GDM were obviously lower than the corresponding parameters of normal fetuses (P < 0.05)., Conclusion: VVI can evaluate the fetal regional left ventricular longitudinal function., (© 2016, Wiley Periodicals, Inc.)

To evaluate placental elasticty in women with gestational diabetes mellitus (GDM) and non-diabetic controls. Thirty-three pregnant women with GDM according to the current criteria of the American Diabetes Association and 43 healthy pregnant women who were admitted to the antenatal clinic were recruited for this case-control study. Elasticity values of both the peripheral and the central parts of the placentas of the patients in both groups were determined by shear wave elastography (SWE) imaging. Mean elasticity values of both the central and the peripheral part of the placentas were significantly higher in GDM pregnancies (p < 0.001). No difference was observed in the mean elasticity values of the central and the peripheral part of the placentas in two groups (p > 0.05). SWE imaging technology might provide a quantitative assessment of the morphological pathologies of placentas in pregnant women with GDM.

Gestational diabetes (GDM) is defined as any degree of glucose intolerance with onset during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mothers and offspring. Women detected to have diabetes early in pregnancy receive the diagnosis of overt, non-gestational, diabetes (glucose: fasting > 126 mg/dl, spontaneous > 200 mg/dl or HbA1c > 6.5 % before 20 weeks of gestation). GDM is diagnosed by an oral glucose tolerance test (OGTT) or fasting glucose concentrations (> 92 mg/dl). Screening for undiagnosed type 2 diabetes at the first prenatal visit (Evidence level B) is recommended in women at increased risk using standard diagnostic criteria (high risk: history of GDM or pre-diabetes (impaired fasting glucose or impaired glucose tolerance); malformation, stillbirth, successive abortions or birth weight > 4,500 g in previous pregnancies; obesity, metabolic syndrome, age > 45 years, vascular disease; clinical symptoms of diabetes (e. g. glucosuria)). Performance of the OGTT (120 min; 75 g glucose) may already be indicated in the first trimester in some women but is mandatory between 24 and 28 gestational weeks in all pregnant women with previous non-pathological glucose metabolism (Evidence level B). Based on the results of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study GDM is defined, if fasting venous plasma glucose exceeds 92 mg/dl or 1 h 180 mg/dl or 2 h 153 mg/dl after glucose loading (OGTT; international consensus criteria). In case of one pathological value a strict metabolic control is mandatory. This diagnostic approach was recently also recommended by the WHO. All women should receive nutritional counseling and be instructed in blood glucose self-monitoring and to increase physical activity to moderate intensity levels- if not contraindicated. If blood glucose levels cannot be maintained in the normal range (fasting < 95 mg/dl and 1 h after meals < 140 mg/dl) insulin therapy should be initiated as first choice. Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. After delivery all women with GDM have to be reevaluated as to their glucose tolerance by a 75 g OGTT (WHO criteria) 6-12 weeks postpartum and every 2 years in case of normal glucose tolerance (Evidence level B). All women have to be instructed about their (sevenfold increased relative) risk of type 2 diabetes at follow-up and possibilities for diabetes prevention, in particular weight management and maintenance/increase of physical activity. Monitoring of the development of the offspring and recommendation of healthy lifestyle of the children and family is recommended.

Twenty-six years ago the St. Vincent Declaration aimed for an achievement of a comparable pregnancy outcome in diabetic and non-diabetic women. However, current surveys clearly show that women with pre-gestational diabetes still feature a much higher risk of perinatal morbidity and even increased mortality. This fact is mostly ascribed to a persistently low rate of pregnancy planning and pre-pregnancy care with optimization of metabolic control prior to conception. In addition, obesity increases worldwide, contributing to a growing number of women with type 2 diabetes at a childbearing age, and a further deterioration in outcome in diabetic women. Development of diabetic embryopathy and fetopathy are known to be related to maternal glycemic control (target: normoglycemia and normal HbA1c, if possible without hypoglycemia). The risk for hypoglycemia is at its greatest in early pregnancy and decreases with the progression of pregnancy due to the hormonal changes leading to a marked increase of insulin resistance. Intensified insulin therapy with multiple daily insulin injections and pump treatment are equally effective in reaching good metabolic control during pregnancy. All women should be experienced in the management of their therapy and on stable glycemic control prior to the conception. In addition, thyroid dysfunction, hypertension as well as the presence of diabetic complications should be excluded before pregnancy or treated adequately in order to decrease the risk for a progression of complications during pregnancy as well as for maternal and fetal morbidity.

Objective: The aim of the study was to investigate standard biometric measurements, such as biparietal diameter (BPD), femur length (FL), abdominal circumference (AC), estimated fetal weight (EFW) and anterior abdomen wall thickness (AAWT) in fetuses complicated by gestational diabetes mellitus (GDM) at the time of GDM screening, and to compare the results with healthy pregnant controls., Methods: A total of 124 pregnant women between 26 and 28 weeks' gestation were included in the study. These patients were divided into two groups based on their 75-g oral glucose tolerance test results. The study group consisted of 55 pregnant women with GDM, and 69 healthy pregnant women constituted our control group., Results: The study groups did not differ with respect to the mean BPD, FL, AC and EFW; however, the mean AAWT was significantly higher in the GDM group, 4.07 ± 0.46 mm versus 3.28 ± 0.37 mm in the control group (p < 0.001)., Conclusions: The only fetal sonographic measurement found to significantly differ between the study groups was the AAWT in 26 weeks at the time of gestational diabetes screening, suggesting that measuring the AAWT may have a role in the evaluation of fetal growth in pregnancies complicated by gestational diabetes.

The aim of the study was to examine interleukin-6 (IL-6) maternal serum concentration at 11 to 14 gestational weeks in normal pregnancies and pregnancies complicated by gestational diabetes mellitus (GDM) and to create first trimester prediction models for GDM. Case-control study conducted in a Fetal Medicine Unit. Study population included 40 GDM cases and 94 controls. Maternal characteristics, first trimester ultrasound markers, biochemical indices, and IL-6 levels were used for our analysis. IL-6 was related to maternal weight among the maternal characteristics, (R(2)=0.0679, p=0.01). IL-6 was increased (p=0.001) in the GDM group (median=2 pg/ml) compared to the control group (median=1.5 pg/ml) even after adjustment for maternal weight. IL-6 was inversely related to birth weight adjusted for gestational age at delivery (r=-0.3382, p<0.001) and glucose levels at oral glucose test. Maternal weight and age were the only predictors of GDM among the maternal characteristics [Detection Rate (DR)=59.4%; for 25% False Positive Rate (FPR); Area Under the Curve (AUC)=0.7291; Model R(2)=0.1096, p<0.001]. IL-6 alone was a significant predictor of GDM (DR=51.3%; for 25% FPR; AUC=0.6731; Model R(2)=0.0616, p<0.001). Combination of maternal characteristics with IL-6 yielded an improved prediction (DR=67.5%; for 25% FPR; AUC=0.7586; Model R(2)=0.1521, p<0.001). IL-6 concentrations are increased at 11-14 weeks in pregnancies with GDM. Combination of maternal characteristics and maternal serum IL-6 levels may provide effective first trimester screening for GDM., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To evaluate the accuracy of the gestation-adjusted projection method of birth weight prediction, as compared to near delivery ultrasound estimated fetal weight, in a gestational diabetic population., Methods: A retrospective cohort was conducted including all women with gestational diabetes who had an ultrasound estimated fetal weight (EFW) between 34(0/7) and 36(6/7) weeks and an additional ultrasound EFW within 7 d of delivery at term. The gestation-adjusted projection (GAP) method was applied to the earlier sonogram, resulting in the GAP predicted birth weight. The GAP predicted weight and the term ultrasound EFW were compared to the actual birth weight. Absolute and percent birth weight errors were compared using paired t-tests., Results: The mean absolute percent errors and mean absolute errors for the GAP method and term ultrasound were 7.7 ± 5.6% versus 7.1 ± 5.1% and 256 ± 184 g versus 236 ± 169 g respectively (p = 0.22 and p = 0.29). The sensitivity of predicting birth weight ≥4000 g was 22% for the GAP method and 28% for term ultrasound, with specificity reaching 97% for both the methods., Conclusion: The GAP method is as accurate as term ultrasound in predicting birth weight in gestational diabetes.

Objective: To evaluate the value of third trimester ultrasound (estimated fetal weight, cheek-to-cheek diameter, sectional Wharton's jelly area, sectional areas and fractional volumes in extremities) to predict birth weight and cord biochemical markers at birth (leptin, insulin, c-peptide, IGF1, erythropoietin and ferritin) in diabetic pregnancies., Method: Prospective study in 49 patients with gestational diabetes. An ultrasound was performed between 32 and 34 weeks. Clinical data were collected, and a blood sample was obtained from cord after birth. ROC curve models were evaluated for 75(th) and 90(th) birth weight percentile. Univariate and multivariate models were used to assess the association between ultrasound and neonatal outcomes., Results: Sectional areas and fractional volumes showed significant differences and highest AUC values for predicting birth weight. A significant association was found for extremities measurements with total birth weight and its percentile. The only marker which showed a significant association to estimated fetal weight was erythropoietin. Sectional areas and fractional volumes related to cord leptin, erythropoietin, insulin and c-peptide., Conclusion: Sectional areas and fractional volumes improve the predictive value of estimated fetal weight in diabetic pregnancies. They also show a predictive association to biochemical changes in cord (leptin, insulin and erythropoietin) related to increased adiposity and risk of fetal hypoxia. © 2015 John Wiley & Sons, Ltd., (© 2015 John Wiley & Sons, Ltd.)

The aim of the study was to assess the use of echocardiographic measurements in newborns of diabetic mothers. Maternal diabetes is associated with an increased risk of morbidity and mortality in pregnancy and in perinatal period. Thirty-five newborns of diabetic mothers (pre- gestational or gestational diabetes; case group) and thirty-five controls (control group), born between January 2009 and December 2012 in Cluj-Napoca (north-west of Romania), were included in this study. A Logiq e ultrasound with an 8 MHz transducer was used to measure echocardiographic parameters. The interventricular septal thickness in case group was higher as compared with control group (at end systole = 6.61 ± 1.64 mm vs. 5.75 ± 0.95 mm, p = 0.0371; at end diastole = 4.61 ± 1.59 mm vs. 3.42 ± 0.70 mm, p = 0.0001). A risk ratio of 2.333 (0.656, 8.298) was obtained for septal hypertrophy. A higher proportion of septal hypertrophy was identified in the newborns of mothers with gestational diabetes compared to the newborns of pregestational diabetes mothers (p = 0.0058). The mean birth weight was significantly higher in newborns of diabetic mothers (3695.57 ± 738.63) as compared with controls (3276.14 ± 496.51; p = 0.0071). Infants born to mothers with diabetes proved to be at a high risk of septal hypertrophy.

Objective: This study aims to derive an estimated fetal weight (EFW) formula in macrosomic fetuses, compare its accuracy to the 1986 Hadlock IV formula, and assess whether including maternal diabetes (MDM) improves estimation., Study Design: Retrospective review of nonanomalous live-born singletons with birth weight (BWT) ≥ 4 kg and biometry within 14 days of birth. Formula accuracy included: (1) mean error (ME = EFW - BWT), (2) absolute mean error (AME = absolute value of [1]), and (3) mean percent error (MPE, [1]/BWT × 100%). Using loge BWT as the dependent variable, multivariable linear regression produced a macrosomic-specific formula in a "training" dataset which was verified by "validation" data. Formulas specific for MDM were also developed., Results: Out of the 403 pregnancies, birth gestational age was 39.5 ± 1.4 weeks, and median BWT was 4,240 g. The macrosomic formula from the training data (n = 201) had associated ME = 54 ± 284 g, AME = 234 ± 167 g, and MPE = 1.6 ± 6.2%; evaluation in the validation dataset (n = 202) showed similar errors. The Hadlock formula had associated ME = -369 ± 422 g, AME = 451 ± 332 g, MPE = -8.3 ± 9.3% (all p < 0.0001). Diabetes-specific formula errors were similar to the macrosomic formula errors (all p = NS)., Conclusions: With BWT ≥ 4 kg, the macrosomic formula was significantly more accurate than Hadlock IV, which systematically underestimates fetal/BWT. Diabetes-specific formulas did not improve accuracy. A specific formula should be considered when macrosomia is suspected., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: The aim of the present study was to investigate the relationship between mid-trimester ultrasound fetal liver length (FLL) and gestational diabetes mellitus (GDM) in a high-risk population., Methods: A prospective study was performed in 331 women with singleton pregnancies who were at high risk of GDM and were undergoing a mid-trimester ultrasound examination. The ultrasound scan at 23 weeks gestation was followed by a 100-g oral glucose tolerance test (OGTT) at 24 weeks gestation. Correlations between FLL and OGTT results at different time points were tested. Receiver operating characteristic (ROC) analysis of FLL as a potential prognostic factor for GDM was also performed., Results: In GDM patients, there was a significant positive correlation (P < 0.01) between FLL and OGTT glycemia immediately before and 60, 120, and 180 min after glucose intake. Mean FLL in GDM was significantly higher than in healthy subjects (41.04 vs 31.09 mm, respectively; P < 0.001). When tested as a potential prognostic factor for GDM, fetal liver measurements showed excellent diagnostic performance. The ROC analysis established a cut-off value of FLL of 39 mm for the prediction GDM, with sensitivity of 71.76%, specificity 97.56%, positive predictive value 91.0%, and negative predictive value 90.9%. The usefulness of FLL measurements was supported by a high area under the ROC curve (90.5%)., Conclusion: In conclusion, there is a strong correlation between FLL and OGTT results, with FLL possibly serving as a valid marker for the prediction of GDM in high-risk populations., (© 2014 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd.)

Objectives: The gestation-adjusted projection method extrapolates birth weight using third-trimester sonography. This technique is shown to be more accurate for sonographic examinations from 34 weeks to 36 weeks 6 days than 37 weeks to 38 weeks 6 days. Our objective was to determine whether even earlier sonographic examinations (31 weeks-33 weeks 6 days) further improves birth weight prediction in patients with diabetes., Methods: We conducted a retrospective cohort analysis of 388 pregnant women with pregestational or gestational diabetes who delivered at 37 weeks or later and had a sonographic examination performed between 31 weeks and 36 weeks 6 days. Sonographic examinations were categorized as "early" if performed at 31 weeks to 33 weeks 6 days or "late" if performed at 34 weeks to 36 weeks 6 days. We estimated birth weight using the gestation-adjusted projection method, compared errors in prediction of birth weight using the t test and Mann-Whitney U test, and performed a 2-sample test of proportions to compare prediction of macrosomia (birth weight >4000 g)., Results: The early and late groups had similar mean gestational ages at birth (38 weeks 4 days versus 38 weeks 5 days; P = .13) and rates of macrosomia (10.7% versus 12.4%; P = .63). The early group had a greater mean absolute error (336 versus 297 g; P = .03) and percent error (9.9% versus 7.9%; P = .01) in birth weight prediction but a lower mean birth weight (3303 versus 3426 g; P = .02). Sensitivity for prediction of macrosomia was 19% in the early group versus 45% in the late group (P = .07), whereas specificity was similar (98% versus 96%; P = .27)., Conclusions: Using the gestation-adjusted projection method in our patients with diabetes, we found that sonographic examinations performed at 34 weeks to 36 weeks 6 days better predicted birth weight than those performed at 31 weeks to 33 weeks 6 days., (© 2015 by the American Institute of Ultrasound in Medicine.)

Background: Nonesterified fatty acids (NEFA) play pathophysiological roles in metabolic syndrome and type 2 diabetes (T2D). In this study, we analyzed the fasting NEFA profiles of normoglycemic individuals at risk for T2D (women with a recent history of gestational diabetes (GDM)) in comparison to controls (women after a normoglycemic pregnancy). We also examined the associations of NEFA species with overweight/obesity, body fat distribution and insulin sensitivity., Subjects and Methods: Using LC-MS/MS, we analyzed 41 NEFA species in the fasting sera of 111 women (62 post-GDM, 49 controls). Clinical characterization included a five-point oral glucose tolerance test (OGTT), biomarkers and anthropometrics, magnetic resonance imaging (n = 62) and a food frequency questionnaire. Nonparametric tests with Bonferroni correction, binary logistic regression analyses and rank correlations were used for statistical analysis., Results: Women after GDM had a lower molar percentage of total saturated fatty acids (SFA; 38.55% vs. 40.32%, p = 0.0002) than controls. At an explorative level of significance several NEFA species were associated with post-GDM status (with and without adjustment for body mass index (BMI) and HbA1c): The molar percentages of 14:0, 16:0, 18:0 and 18:4 were reduced, whereas those of 18:1, 18:2, 20:2, 24:4, monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA) and total n-6 NEFA were increased. BMI and the amount of body fat correlated inversely with several SFA and MUFA and positively with various PUFA species over the whole study cohort (abs(ρ)≥0.3 for all). 14:0 was inversely and BMI-independently associated with abdominal visceral adiposity. We saw no correlations of NEFA species with insulin sensitivity and the total NEFA concentration was similar in the post-GDM and the control group., Conclusion: In conclusion, we found alterations in the fasting NEFA profile associated with a recent history of gestational diabetes, a risk marker for T2D. NEFA composition also varied with overweight/obesity and with body fat distribution, but not with insulin sensitivity.

The purpose of this review is to discuss the established role of ultrasound (US) in the management of pregnancy complicated by diabetes mellitus (DM), as well as new developments with regard to the use of US in this situation. We choose to explore the role of US in pregnancy complicated by DM in three areas: (1) Role of US in estimation of fetal weight. (2) Role of US in diagnosis of congenital malformation. (3) Role of US in monitoring diabetic pregnant patients.

Objective: To establish a nomogram of fetal urine production according to gestational age as a predictor for fetal well-being in normal and diabetic women., Study Design: Prospective observational study included 180 pregnant women classified into two groups: Group I (120 women) without any medical complications and Group II (60 women) with gestational diabetes mellitus (GDM). The fetal bladder is measured by the virtual organ computer-aided analysis VOCAL 3D ultrasound scanner., Results: There was a significant positive correlation between gestational age and fetal urine production rate (UPR) (the mean UPR rate in normal pregnancy at 25, 30, 35, 40 weeks were 12.3, 14.38, 56.13 and 90.73 ml/h, respectively). There was no significant difference regarding UPR ml/h between women with normal pregnancy and those with controlled GDM (p = 0.9). There was a statistically significant difference regarding UPR ml/h between women with normal pregnancy and those with uncontrolled GDM (p = 0.012) and a statistically significant difference between women with controlled GDM and those with uncontrolled GDM (p = 0.03)., Conclusion: Fetal UPR is considered to be more reliable as an assessment method for fetal well-being and shows significant increase in patients with uncontrolled gestational DM.

Purpose: To determine causes of polyhydramnios and the respective perinatal outcome., Materials and Methods: We retrospectively analyzed cases with polyhydramnios at the Medical University Graz, Austria from 2003 - 2011. Inclusion criteria were single deepest pocket ≥ 8  cm, amniotic fluid index ≥ 25  cm, each of the latter parameters > 95th percentile or subjective impression. Etiologies, including TORCH infection, diabetes and congenital malformations, as well as perinatal outcome were evaluated., Results: Out of 860 singleton pregnancies with polyhydramnios, 2.9 % had positive TORCH serology, 8.5 % had congenital anomalies, 19.8 % had maternal diabetes, and 68.8 % were idiopathic. The most common fetal anomalies were cardiac defects (32.9 %). Elective caesarean sections were more common in the groups with malformations and maternal diabetes. Low birth weight combined with severe polyhydramnios or maternal diabetes was associated with malformations., Conclusion: Diagnosis of polyhydramnios should prompt glucose-tolerance testing, detailed sonography including fetal echocardiography, and TORCH serology. Especially pregnancies with polyhydramnios and small fetuses as well as those with maternal diabetes should be carefully evaluated for malformations., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: To assess fetal cardiac structure and function and to evaluate the efficacy of routine fetal echocardiography for detection of fetal cardiac abnormalities in women with normal pregnancies and those with gestational diabetes mellitus., Methods: In this prospective study, we studied fetal cardiac structure and function in 294 uncomplicated singleton pregnancies and 302 pregnancies complicated by gestational diabetes. Fetal echocardiography (2-dimensional sonography and pulsed wave Doppler imaging) was used to assess functional parameters and to detect any cardiac structural abnormality. Data from clinical and echocardiographic evaluations of neonates at birth and 3 months were obtained to confirm the antenatal findings., Results: The mean maternal age ± SD was 28.9 ± 5.0 years in the diabetes group and was comparable to that of women with normal pregnancies. The mean hemoglobin A1c value was 6.3%, and the mean body mass index was 28.0 kg/m(2). The systolic function as assessed by the ejection fraction increased significantly in the diabetes group compared to the normal pregnancy group independent of glycemic control (P < .001). The pulsed wave parameters (early diastolic peak flow velocity and early-to-late diastolic peak flow velocity ratio) were significantly different between the groups (P < .001). The interventricular septum and fetal ventricular wall thicknesses were significantly increased in the presence of gestational diabetes (P < .001). No major fetal cardiac structural anomaly was detected in either group. On follow-up after delivery, all neonates were assessed clinically and by transthoracic echocardiography to rule out congenital defects., Conclusions: In our study, significant increases in the interventricular septum and ventricular wall thicknesses were detected in the presence of gestational diabetes mellitus. Interestingly, none of the neonates of pregnant women with gestational diabetes were found to have echocardiographic evidence of congenital heart disease., (© 2014 by the American Institute of Ultrasound in Medicine.)

Objective: To evaluate the blood flow in orbital arteries in patients with gestational diabetes mellitus (GDM)., Material: We have examined 65 GDM patients and 38 healthy pregnant women at 28-32 weeks. Doppler parameters were assessed in ophthalmic, central retinal and short posterior ciliary arteries., Results: In ophthalmic arteries V2 was significantly higher and RI lower in GDM. In the subgroup treated with insulin V1 and V2 in ciliary artery and V2 in central retinal artery were significantly lower and PI in ciliary artery was higher when compared to subgroup on diet., Conclusion: Doppler examination can be useful in detection of pre-clinical ophthalmological changes in GDM patients.

Objective: To perform a systematic review and meta-analysis of randomized controlled trials assessing ultrasound-guided versus conventional management in women with a broad severity-spectrum of gestational diabetes mellitus., Design: Systematic review and meta-analysis of trials published until August 2012., Setting: PubMed and Web of Science databases., Study Selection and Methods: Eighteen studies were reviewed in full text. Eligibility criteria were (i) randomized controlled trials comparing metabolic management in women with gestational diabetes mellitus and ultrasound-based vs. the conventional management to assess fetal growth, (ii) representative of the whole spectrum of hyperglycemia and fetal growth, (iii) data on perinatal outcomes. Review Manager 5.0 was used to summarize the results., Results: Two studies fulfilled inclusion criteria. The ultrasound-guided group had a lower rate of large-for-gestational age newborns (relative risk 0.58, 95% confidence interval 0.34-0.99), macrosomia (relative risk 0.32, 95% confidence interval 0.11-0.95) and abnormal birthweight (small/large-for-gestational age, relative risk 0.64, 95% confidence interval 0.45-0.93) and a higher rate of insulin treatment (relative risk 1.58, 95% confidence interval 1.14-2.20). The number of women with gestational diabetes with a need to treat to prevent an additional newborn with abnormal birthweight was 10., Conclusions: In women with a broad severity-spectrum of gestational diabetes mellitus, ultrasound-guided management improves birthweight distribution, but increases the need for insulin treatment. More research is needed in this area because results are derived from a limited number of patients., (© 2013 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background/aims: Diabetes is well-known to influence endothelial function. Endothelial function and blood flow regulation might be different in diabetic and non-diabetic pregnancy. However, the impact of umbilical blood flow regulation in gestational diabetes on fetal development is unknown so far., Methods: In a prospective birth cohort study, we analyzed the association of the umbilical artery Doppler indices (pulsatility index, resistance index and systolic/diastolic ratio) and fetal size measures (biparietal diameter, head circumference, abdominal circumference, femur length and birth weight) in 519 non-gestational diabetes mellitus pregnancies (controls) and 226 gestational diabetes mellitus pregnancies in middle (day 160.32 ±16.29 of gestation) and late (day 268.12 ±13.04 of gestation) pregnancy., Results: Multiple regression analysis considering confounding factors (gestational day of ultrasound examination, offspring sex, maternal body mess index before pregnancy, maternal age at delivery, maternal body weight at delivery and maternal hypertension) showed that umbilical artery Doppler indices (pulsatility index, resistance index and systolic/diastolic ratio) were associated with fetal head circumference and femur length in middle gestational diabetes mellitus pregnancy but not in non-gestational diabetes mellitus pregnancy. Head circumference, biparietal diameter, abdominal circumference and femur length in mid gestation were smaller in fetus of gestational diabetes mellitus pregnancy versus non-gestational diabetes mellitus pregnancy. In contrast to non-gestational diabetes mellitus pregnancy in late gestation, umbilical artery Doppler indices in gestational diabetes mellitus pregnancy were not associated with ultrasound measures of fetal growth. Birth weight was slightly increased in gestational diabetes mellitus pregnancy as compared to non-gestational diabetes mellitus pregnancy., Conclusions: The impact of umbilical blood flow on fetal growth is time dependent in human gestational diabetes mellitus and non-gestational diabetes mellitus pregnancy. In gestational diabetes mellitus pregnancy umbilical blood flow is critical for organ development in much earlier stages of pregnancy as compared to non-gestational diabetes mellitus pregnancy. The physiological and molecular pathways why there is a catch up growth in later times of gestational diabetes mellitus pregnancy resulting in larger gestational diabetes mellitus babies at birth needs to be addressed in further studies.

Women with gestational diabetes mellitus (GDM) are at increased risk for cardiovascular diseases (CVD) events compared with women without GDM. The aim of the present study was to evaluate 200 parameters of the heart electric field in 35 women with GDM under optimal glycemic compensation compared to 32 healthy pregnant women. All examinations were performed in the 36th week of gestation. The parameters in ECG body surface mapping (BSM) were registered by the diagnostic system Cardiag 112.2. The absolute values of maximum and minimum in depolarization and repolarization isopotential, isointegral and isoarea maps were not significantly different between the groups. These findings correspond to the result of heart rate variability examination. However BSM revealed the significant prolongation of QRS complex (p=0.05), shortening of ventricular myocardial activation time (ICHVAT) (p=0.01), prolongation of mean QT duration (p=0.01) and increase of QT interval dispersion (p=0.01) in women with GDM. Duration of QRS and ICHVAT significantly correlated with interventricular septum and posterior wall thickness in GDM group, QTd interval correlated significantly with HbA1C level. We conclude that despite of optimal metabolic control several significant abnormalities detected by ECG BSM are still present in patients with GDM.

Objectives: This study aimed to determine whether antenatal ultrasound measurements of fetal soft-tissues and liver can predict macrosomia in women with pregestational diabetes., Methods: Fetal biometry, soft-tissue thickness (anterior abdominal wall [STAW], thigh [STT], upper arm [STA], scapular [STS]) and liver size were measured sonographically at 23, 28, 31 and 34 weeks of gestation. Large for gestational age (LGA) was defined as a birth weight greater than 90th percentile for gestational age on standard curves adjusted for maternal height and weight, parity and fetal gender. The area (±standard error) under receiver operating characteristic (AUROC) curves were also calculated., Results: A total of 29 pregnant women with pregestational diabetes were included, and a total of 663 measurements taken. Fifteen neonates were LGA. There was no significant difference in fetal soft-tissue thickness at 23, 28 and 31 weeks between the LGA and non-LGA neonates. In contrast, at 34 weeks, fetal soft-tissues were significantly thicker in LGA neonates (P<0.05), but with no difference in liver surface area between the two groups. The specificity and sensitivity of 34-week ultrasonography to detect macrosomia was 78.6% and 66.7%, respectively, for abdominal circumference (AC), 71.4% and 93.3% for STT, 85.7% and 80.0% for STA, and 71.4% and 86.7% for STAW. No parameter was more powerful than the others. The best AUROC curves were found for AC (0.807), STT (0.821), STA (0.855) and STAW (0.821)., Conclusion: Third-trimester sonographic measurements of fetal soft-tissue may help to detect macrosomia in pregnancies complicated by pregestational diabetes., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objectives: To assess first-trimester placental perfusion, reflected in the uterine artery (UtA) pulsatility index (PI), in pregnancies complicated by gestational diabetes mellitus (GDM), with or without pre-eclampsia (PE), compared with those unaffected by GDM., Methods: UtA-PI was measured at 11 + 0 to 13 + 6 weeks' gestation in 1037 singleton pregnancies that subsequently developed GDM and in 56 649 normoglycemic controls. The measured mean UtA-PI was converted to multiples of the expected normal median (MoM), corrected for maternal weight, racial origin and gestational age, and the median MoM values in the two groups were compared., Results: The incidence of PE was higher in pregnancies with GDM than in controls (4.0% vs 2.3%, respectively; P =  0.001). However, there were no significant differences in the median UtA-PI MoM between the groups (1.00 (interquartile range (IQR), 0.82-1.21) vs 1.00 (IQR, 0.81-1.21); P = 0.73). The median UtA-PI in patients who developed PE was higher than in those who did not develop PE, regardless of the development of GDM., Conclusions: First-trimester placental perfusion, as assessed by UtA Doppler examination, is not impaired in women who subsequently develop GDM. The increased prevalence of PE in women with GDM cannot be attributed to impaired placentation., (Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.)

Objectives: The aim of our study was to evaluate placental three-dimensional power Doppler indices in diabetic pregnancies in the second and third trimesters and to compare them with those of the normal controls., Methods: Placental vascularization of pregnant women was determined by three-dimensional power Doppler ultrasound technique. The calculated indices included vascularization index (VI), flow index (FI), and vascularization flow index (VFI). Uncomplicated pregnancies (n = 113) were compared with pregnancies complicated by gestational diabetes mellitus (n = 56) and diabetes mellitus (n = 43)., Results: The three-dimensional power Doppler indices were not significantly different between the two diabetic subgroups. All the indices in diabetic patients were significantly reduced compared with those in non-diabetic individuals (p < 0.001). Placental three-dimensional power Doppler indices are slightly diminished throughout diabetic pregnancy [regression coefficients: -0.23 (FI), -0.06 (VI), and -0.04 (VFI)] and normal pregnancy [regression coefficients: -0.13 (FI), -0.20 (VI), and -0.11 (VFI)]. The uteroplacental circulation (umbilical and uterine artery) was not correlated significantly to the three-dimensional power Doppler indices. If all placental indices are low during late pregnancy, then the odds of the diabetes are significantly high (adjusted odds ratio: 1.10)., Conclusions: A decreased placental vascularization could be an adjunct sonographic marker in the diagnosis of diabetic pregnancy in mid-gestation and late gestation., (© 2013 John Wiley & Sons, Ltd.)

Objectives: To construct a clinical management matrix using serial fetal abdominal circumference measurements (ACMs) that will predict normal birth weight in pregnancies complicated by gestational diabetes (GDM) and reduce unnecessary ultrasound examination in women with GDM., Study Design: Retrospective cohort study of 144 women with GDM in a specialist obstetric-diabetes clinic. Women with GDM who delivered singleton infants were identified from a clinical register. Regression analysis was used to identify associations between serial ACMs, maternal parameters and normal birth weight (birth weight between the 10th and 90th percentiles). Predictive clinical models were designed with the aim of identifying normal birth weight infants with the lowest number of fetal ultrasound scans., Results: Compared to mothers of large-for-gestational-age (LGA) infants, mothers of normal weight infants had lower fasting glucose measurements at diagnosis (5.9 mmol/l±1.0 vs. 6.6 mmol/l±0.7, p<0.05), lower maternal weight at delivery (90 kg±17 vs. 96 kg±17, p<0.05), and a lower rate of prior LGA infants (31% vs. 60%, p<0.05). Maternal weight and a history of prior LGA delivery were identified as useful predictors of fetal birth weight in predictive models. Serial ACMs below the 50th, 75th and 90th percentiles could predict normal birth weight with 100%, 97% and 96% positive predictive value respectively when used in these risk factor based models. Two measurements sufficed in low-risk pregnancies., Conclusion: Serial ACMs can predict normal birth weight in GDM., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: To detect the structural and functional changes of fetal hearts in diabetic pregnancies by using Doppler echocardiography., Methods: This prospective study included 119 pregnant women divided into three groups. Group 1 included 47 pregnant patients with pre-existing diabetes mellitus (DM), group 2 included 40 patients with gestational diabetes and group 3 included 32 non-diabetic pregnant women. M-mode echocardiography was used to measure the thickness of the fetal ventricular walls and interventricular septum. The mitral and tricuspid early (E) and late (A) diastolic velocities and the ventricular shortening fraction were measured., Results: HbA1c % was significantly lower in gestational diabetes group compared with the pre-existing diabetes group. The interventricular septum was significantly thicker in the pre-existing diabetes group compared with other groups. Tricuspid and mitral E/A ratios were significantly lower in the pre-existing diabetes group compared with gestational diabetes and control groups. Moreover, there were no significant differences in the tricuspid and mitral E/A ratios between gestational diabetes group and the control group. The right and left ventricular shortening fractions were similar in the three groups., Conclusion: Fetuses of women with well-controlled gestational diabetes lack the diastolic dysfunction that is present in fetuses of women with pre-existing diabetes.

Objective: To understand if ultrasound biometric evaluation at 30-32 weeks of gestation is a valuable screening tool for the detection of small-for-gestational-age (SGA) and large-for-gestational-age (LGA) infants at birth in a low risk population., Study Design: We enrolled 1848 pregnant women with singleton pregnancy undergoing routine fetal biometry. We divided the infants into four groups: moderate SGA, severe SGA, moderate LGA and severe LGA. We considered third-trimester estimated fetal weight (EFW), abdominal circumference (AC), EFW centile (EFWc), AC centile (ACc) and compared their prediction toward SGA and LGA to determine which of these parameters was the best estimator for fetal size. Then we took the strongest predictive value and added all history-related and ultrasound factors to run a stepdown multivariate logistic regression. All the variables were then dichotomized and sensitivity models only for statistically significant parameters were calculated., Results: We identified the following predictive factors for each outcome: for severe SGA: EFWc with p<0.001, uterine artery pulsatility index (UtA PI) with p<0.002. For moderate SGA: EFWc with p<0.001, UtA PI with p<0.004, maternal preeclampsia p<0.002. For moderate and severe LGA: EFWc with p<0.001., Conclusion: We can detect in a low-risk population a group at risk of growth deviations. Adding Doppler velocimetry to 30-32 weeks EFWc improves the specificity (84%) regarding SGA newborns, maintaining a good sensitivity (71%), and reducing the population to be re-screened from 27 to 17%. An ultrasound examination at 34-36 weeks or the clinical assessment of maternal risk factors remain the best tools for LGA newborns., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Purpose: Excessive fetal fat as the hallmark of GDM pregnancy complications is one consequence of fetal hyperinsulinism. Noninvasive methods for fetal surveillance and measurement of fetal fat are needed. The purpose of this study was to test the hypothesis that measurements of the fetal anterior abdominal wall thickness (AAWT) in women with GDM will allow early detection of fetal hyperinsulinism., Materials and Methods: Amniocentesis was performed between 28 and 32 weeks of gestation (wks) in 220 women with GDM (diagnosed by 75 g oGTT at 24 to 28 wks). Amniotic fluid insulin levels (AFIL) were determined by a commercially available radioimmunoassay. Transabdominal ultrasound provided fetal biometric measurements following standard procedures and the AAWT including fetal skin and subcutaneous tissue at the time of amniocentesis. Maternal parameters (weight, BMI, oGTT blood glucose levels and mean daily blood glucose levels) were correlated with fetal biometric data and with AFIL., Results: There was no difference in AAWT in women with GDM and no correlation with mean AFIL. AFIL also did not correlate with any other fetal measurement or with mean oGTT blood glucose levels. AFIL only showed a correlation with maternal weight (p = 0.02) and maternal BMI (p = 0.01). The correlation was present for values both before pregnancy and at the time of amniocentesis., Conclusion: In the early third trimester, AAWT measurements do not correlate with fetal insulin levels., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To evaluate the fetal cardiac function by modified myocardial performance index (Mod-MPI) in pregnant diabetic patients., Methods: Modified myocardial performance index was measured in fetuses of patients with diabetes (DM) between 30 and 40 weeks of gestation. The isovolumetric contraction time, isovolumetric relaxation time and ejection time were measured. Mod-MPI was calculated as (isovolumetric contraction time + isovolumetric relaxation time)/ejection time. Results were analyzed by using one-way analysis of variance (post hoc Bonferroni correction), Chi-square and Student's test., Results: Modified myocardial performance index values of fetuses from DM mothers were significantly higher than controls (0.43 vs 0.37, P < 0.0001), and it was not different between gestational versus pregestational DM (0.42 vs 0.45, P = 0.18). Mod-MPI was also higher in the presence of polyhydramnios (0.49 vs 0.41, P < 0.0001), insulin use (0.46 vs 0.40, P < 0.05), and large for gestational age fetuses (0.49 vs 0.40, P < 0.0001). There were no significant differences in Mod-MPI between newborns with versus without neonatal complications such as hypoglycemia or polycythemia., Conclusions: In fetuses of DM mothers, evaluation of the Mod-MPI identifies those with worse maternal disease and large fetal size., (© 2012 John Wiley & Sons, Ltd.)

Objective: To evaluate diagnostic accuracy and efficiency of ultrasound markers of gestational diabetes (GDM) and propose an ultrasound based scoring system suitable for screening (UGDS)., Methods: 110 women with singleton pregnancies and established maternal and/or pregnancy related risk factors for GDM were scanned at/or after 24 weeks gestation followed by administration of a 3 hour 100-gram oral glucose tolerance test (oGTT). A number of ultrasound markers were determined/measured, including fetal adipose subcutaneous tissue, asymmetrical macrosomy, cardiac circumference, cardiac width, and interventricular septum thickness, immature appearance of placenta, intensified breathing movements, polyhydramnios and placental thickness. Each ultrasound GDM marker was assigned one point to create the ultrasound gestational diabetes screening score (UGDS)., Results: All ultrasound GDM markers were positively correlated to the disease P < 0.0001. The strongest independent predictor of GDM was an immature appearance of placenta (RR 40.1 95% CI 5.9-271.0, P < 0.0001). Receiver operator characteristics (ROC) showed an area under the curve of 95.7% confirming good ability of UGDS to discriminate between positive and negative oGTT. We propose a UGDS score of 4 providing sensitivity of 90.9%, and specificity 89.6%., Conclusions: This study suggests that UGDS is a good predictor of GDM.

Objective: To evaluate the relationship between gestational diabetes mellitus (GDM) and fetal activity., Materials and Methods: We prospectively studied 18 pregnant patients with GDM and 20 pregnant patients with normal glucose screening test. An ultrasound equipment was used to perform a 30 min transabdominal sonographic recording for each patient. Each ultrasound exam was recorded using a DVD recorder. Fetal activity was analyzed using duration and number of episodes of fetal breathing and body movements. The recordings were analyzed using a stopwatch in order to accurately evaluate each recording. The data was statistically analyzed using the parametric and non-parametric t-test., Results: The results of the study indicated that there was a significant correlation (p = 0.007) between the duration of fetal breathing movement and GDM. Fetuses of mothers suffering from GDM had a significantly longer duration of fetal breathing movements compared with fetuses of non diabetic mothers. In addition, the total duration of fetal activity (time of fetal body movements plus fetal breathing movements) was significantly higher (p = 0.005) in GDM compared with non GDM pregnancies. The difference in fetal body movements between GDM and normal pregnancies was not statistically significant., Conclusion: The results of this study support the hypothesis that GDM has a direct influence on fetal activity. The significance of this finding should be further evaluated.

Objective: The aim of this study was to investigate the effects of HbA1c levels and umbilical cord thickness upon birth weight, particularly in pregestational and gestational diabetic patients., Method: Pregnant women were included in the study and were divided into two groups. The first group consisted of patients who were diagnosed with pregestational or gestational diabetes mellitus. The control group consisted of pregnant women who were not diagnosed with pregestational or gestational diabetes mellitus. Ultrasound examination was performed twice. Examinations were performed at 27-28 weeks and 36-37 weeks of gestation, respectively. During ultrasound examinations, fetal anthropometric parameters, biparietal diameter, abdominal circumference, femur length and estimated fetal weight (which was calculated automatically according to Hadlock's formula) were measured. Additionally, the sonographic cross-sectional areas of the umbilical cord, the umbilical arteries and the umbilical vein were measured in a free loop of the umbilical cord, using the software of the ultrasound machine. The cross-sectional area of Wharton's jelly was computed by subtracting the cross-sectional area of the vessels from that of the umbilical cord. HbA1c levels were measured for diabetic patients., Results: At 27-28 gestational weeks, umbilical cord area and Wharton's jelly values were found to be statistically different in macrosomic fetuses compared with non-macrosomic fetuses for both groups (for cord area, P = 0.012; for Wharton's jelly, P = 0.001). Additionally, umbilical cord diameter vein and artery values were not statistically different between the two groups when macrosomic fetuses were compared with non-macrosomic fetuses. At 36-37 gestational weeks, when the relationship between umbilical cord components and birth weight was examined, there was a statistically significant difference when comparing macrosomic fetuses with non-macrosomic fetuses. There was a statistically significant correlation between umbilical cord area, umbilical cord diameter and fetal weight estimation at 36-37 gestational weeks. HbA1c values and fetal macrosomia did not show a statistically significant relationship (P = 0.701)., Conclusion: A significant relationship between umbilical cord components and birth weight was not specific for the diabetic group. There was a significant relationship between birth weight and umbilical cord components for the control group as well. If the estimated fetal weight is combined with umbilical cord components, macrosomic fetuses can be predicted with more accuracy.

Objective: To evaluate the fetal cardiac function in gestational diabetes mellitus (GDM) pregnancies under different maternal glycemic controls., Methods: Forty four GDM mothers received 78 fetal echocardiographic evaluations at three gestational periods (<28, 28-34 and >34 weeks) and were divided into poorly-(DM1) and well-(DM2) controlled groups according to their glycemic control at examination. Seventy uncomplicated mothers were selected as controls. Parameters of fetal cardiac anatomy and function were measured and analyzed., Results: GDM fetuses' cardiac ventricular walls were thicker than controls', and the differences between DM1 and DM2 were not significant except for end-diastolic left ventricular walls. In both GDM groups, the aortic flow velocities increased earlier than pulmonary artery and DM1 fetuses changed earlier than DM2 ones. GDM fetuses' left atrial shortening fraction was smaller than the controls' in the period of ⩾34 weeks and negatively correlated with thicknesses of left ventricular walls and interventricular septum in DM1 fetuses (r=-0.438 and -0.506). The right ventricular diastolic function in DM1 and DM2 fetuses decreased after the period of 28-34 weeks and in the period of >34 weeks respectively. Tei index of both left and right ventricles increased in DM1 group after the period of <28 weeks and in DM2 group only in the period of ⩾34 weeks, with no significant differences between DM1 and DM2 groups in this period., Conclusion: Fetuses of GDM mothers showed cardiac function impairments. Good maternal glycemic control may delay the impairments, but cannot reduce the degree. Some cardiac changes in GDM fetuses were similar to those in pregestational diabetic pregnancies except for several parameters and their changing time., (Copyright © 2012 The Editorial Board of Biomedical and Environmental Sciences. Published by Elsevier B.V. All rights reserved.)

Background: Large for gestational age (LAG) neonates who had been exposed to an intrauterine environment of either diabetes or maternal obesity are at increased risk of developing the metabolic syndrome. This can be explained by exposure to high glucose and insulin levels in utero which alter fetal adaptation and programming., Objectives: The aim of the study was to evaluate the onset of preclinical atherosclerosis in utero., Methods: We measured umbilical artery wall thickness (ruWT) in the third trimester by obstetric ultrasound and umbilical artery intima-media thickness (uIMT) in pathologic specimens of umbilical cords obtained shortly after delivery and investigated the relation between these measurements and serum insulin level and C-peptide level in cord blood and assessed insulin resistance with the homeostasis model assessment of insulin resistance (HOMA-IR) in infants of diabetic mothers (IDMs), i.e. the study group, which was divided into a large for gestational age group (LGA)-IDM group and an appropriate for gestational age group (AGA)-IDM group and compared with a control group., Results: The LGA-IDM group had significantly higher insulin (p < 0.001), C-peptide (p = 0.018) and HOMA-IR levels (p < 0.001) compared with the AGA-IDM and control groups. The LGA-IDM group had significantly larger ruWT (p = 0.013) and uIMT (p < 0.001) compared with the AGA-IDM and the control groups. The LGA-IDM group had increased uIMT and ruWT that correlated with the severity of maternal hyperglycemia., Conclusions: Measurement of ruWT in the third trimester is feasible, reproducible and strongly correlated with pathological serum insulin, C-peptide in cord blood and HOMA-IR levels., (Copyright © 2012 S. Karger AG, Basel.)

Aims: To investigate the possible association between maternal diabetes mellitus and increased yolk sac diameter (YSD)., Methods: We searched the Early Pregnancy Unit database to identify singleton pregnancies with measurements of embryonic crown-rump length (CRL) and YSD at 6-10 weeks of gestation and subsequent delivery of phenotypically normal neonates. We compared the YSD in patients with pre-gestational and gestational diabetes with those who were unaffected by diabetes., Results: A total of 3,686 cases were identified including 43 (1.2%) with type 1 diabetes, 31 (0.8%) with type 2 diabetes and 71 (1.9%) who subsequently developed gestational diabetes. The measured YSD in both the diabetic and non-diabetic groups were expressed as differences from the expected normal mean for CRL (Δ values). There were no significant differences in ΔYSD between the groups. The median (IQR) ΔYSD was 0.01 (-0.33 to 0.37) mm in the unaffected group, 0.01 (-0.35 to 0.51) mm in type 1 diabetes, -0.02 (-3.44 to 0.27) mm in type 2 diabetes and 0.01 (-0.28 to 0.35) mm in gestational diabetes., Conclusion: After exclusion of miscarriages and embryopathies, pre-gestational and gestational diabetes are not associated with altered YSD., (Copyright © 2011 S. Karger AG, Basel.)

Purpose: Gestational diabetes (GDM) is related to increased maternal and neonatal morbidity. Maternal hyperglycemia causes fetal hyperglycemia and consequently fetal hyperinsulinism. The impaired glucose metabolism will lead to prenatal and postnatal complications. The main issue of this study is the influence of GDM in evaluating Doppler flow measurements in the umbilical artery (UA)., Materials and Methods: Pregnancies from gestational age > 34 + 0 were included in this case control study. The study period was 18 months. The last Doppler measurement in pregnancies with GDM (diet-controlled and insulin-dependent) was compared to the healthy control group. Our collected data included the last prenatal Doppler flow recordings (resistance index (RI) in the umbilical artery (UA))., Results: In women with diet-controlled GDM, a significant decrease in the RI (p = 0.002) in the UA has been observed. Insulin-treated diabetic and healthy control pregnancies showed no difference in the RI., Conclusion: Doppler flow examinations with RI measurements in patients with GDM differ significantly with respect to healthy controls. In insulin-treated women the RI indices are not different from the control group, while in the diet-controlled group a significant decrease was noted and additionally might show a possible maternal metabolic dysfunction., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: The purpose of this study was to evaluate the ability of early third-trimester sonography to predict large for gestational age (LGA) birth weights in women with diabetes mellitus., Methods: We identified women with nonanomalous singleton gestations and pregestational and gestational diabetes mellitus who underwent sonographic examinations between gestational ages of 28 weeks and 32 weeks 6 days and subsequently delivered at 37 weeks or later. Using a cohort study design, we compared data from women with an estimated fetal weight at or above the 75th percentile (exposed group) with data from those with an estimated fetal weight below the 75th percentile (unexposed group). The primary outcome variable was LGA birth weight, defined as a birth weight of greater than 90% for gestational age., Results: Eighty-six women met inclusion criteria over a 3-year period: 40 were in the exposed group, and 46 were in the unexposed group. The mean body mass indices ± SD at delivery were similar for both groups: 35.4 ± 8.2 kg/m(2) exposed versus 35.0 ± 8.2 kg/m(2) unexposed (P = .80). There was no difference in the number of women with gestational diabetes mellitus: 40% exposed versus 39% unexposed (P = .90). Neonates whose early third-trimester estimated fetal weight was at or above the 75th percentile were significantly more likely to be LGA at birth compared with neonates whose early third-trimester estimated fetal weight was below the 75th percentile: 65% exposed versus 15% unexposed (P < .001; odds ratio, 10.3; 95% confidence interval, 3.7-29.1). There was no significant difference in cesarean delivery rates: 60% exposed versus 44% unexposed (P = .13), Conclusions: Measurements obtained by early third-trimester sonographic fetal biometry are reasonably predictive of fetal LGA birth weights at term.

Objective: To evaluate the effect of gestational diabetes mellitus (GDM) on fetal liver growth during the third trimester., Methods: We performed a longitudinal study of pregnant women recruited at the time of GDM screening (24 to 28 weeks of gestation), with follow-up visits at 32 weeks, 36 weeks, and delivery. Women with GDM were followed with nutritional recommendations and insulin when necessary according to the Canadian Diabetes Association guidelines. Fetal liver volume was evaluated using 3-D ultrasound at each antenatal visit, and fetal liver growth was compared between women with and without GDM., Results: Twenty-seven women were recruited, 10 with normal glucose tolerance (NGT) and 17 with confirmed GDM, five who required insulin and 12 who were treated by diet only. We found no difference in fetal liver volume between groups at any of the three visits, and median birth weight was also similar between groups. On the other hand, we found a strong correlation between fetal liver volume at 36 weeks' gestation and birth weight (ρ = 0.61, P < 0.001)., Conclusions: In our preliminary study, we found that fetal liver volume could be a strong predictor of infant birth weight independent of GDM status. This suggests that fetal liver volume of offspring of women with NGT is similar to that of offspring of women with GDM treated following recommended targets. Larger studies are required.

Background and Aims: This study was planned to evaluate whether increased nuchal translucency (NT) thickness in the first trimester of gestation can be related to onset of gestational diabetes mellitus (GDM) during pregnancy., Methods: From January 2006 to August 2008, a group of 678 singleton pregnancies who had developed GDM has been selected as a study group among a total of 3966 pregnant women who had undergone first trimester screening for aneuploidies at 11-14 weeks of gestation. A group of 420 single pregnant women with physiological pregnancy were enrolled as control group. Both fetal structural and karyotype's anomalies were excluded in the two groups. NT was mesured by a Fetal Medicine Foundation certificated operator; GDM was diagnosed at 24-28 weeks of gestation following Carpenter and Coustan criteria. In the analyses of continuos variables, study and control group were compared by Student's t-test and Anova test., Results: There was no significative difference (p = 0.585) between NT values in the study (mean = 1.56) and control group (mean = 1.54)., Conclusions: NT thickness does not show a significative increase in those women who subsequently develop GDM. Therefore, NT assessment does not prove to be an useful ultrasound parameter for predicting GDM onset during pregnancy.

Fetal growth scans and amniotic fluid assessments are used to evaluate fetal well-being in women with pregestational and gestational diabetes. These measurements reflect placental function and guide clinicians in timing of delivery to decrease morbidity to mother and infant. Ultrasound assessments may be performed by nurses in the perinatal setting. Nurses who perform these examinations have a unique opportunity to provide teaching and support for women with diabetes while helping to improve perinatal outcomes., (© 2011 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Women with gestational diabetes mellitus (GDM) are at high risk of subsequently developing type 2 diabetes mellitus which is an important cardiovascular risk factor. We have evaluated whether preclinical morphological and functional arterial changes are present in GDM. Diameter, intima-media thickness (IMT), intima-media cross-section area (IMCSA) and elasticity features (compliance, distensibility coefficient, circumferential strain, stiffness index (SI) α and β, incremental elastic modulus) of the common carotid arteries (CCA) were studied in the 3rd trimester in 25 women with GDM, and 17 normal pregnant women matched for age and body mass index using an ultrasonographic vessel wall-movement tracking system and applanation tonometry. Mean IMT, IMCSA and SI α tended to be larger, whereas compliance was smaller in women with GDM but none of these differences were significant. Serum glucose (4.99 ± 0.51 vs. 4.79 ± 0.61 mmol/L, p=0.37) and HbA1c (5.33 ± 0.27 vs. 5.36 ± 0.47 mmol/L, p=0.85) proved normoglycemia in both groups. In conclusion, by the combination of methods we applied in this case control study, neither morphological nor functional characteristics of large elastic arteries differ significantly between well-treated normoglycemic women with GDM and non-diabetic pregnant women in the 3rd trimester.

Endothelial dysfunction has been observed systemically in women with gestational diabetes (GDM). Important cardiovascular adaptations occur during pregnancy, including enhanced endothelium-dependent vasodilation in systemic and uterine arteries, which are necessary to ensure the health of both mother and fetus. The effects of GDM, however, on uterine artery function and the possible mechanisms that mediate endothelial dysfunction remain unknown. The aim of this study was to utilize a mouse model of GDM to investigate (a) effects on uteroplacental flow, (b) endothelial function of uterine and mesenteric arteries, and (c) possible mechanisms of any dysfunction observed. Pregnant mice heterozygous for a leptin receptor mutation (Lepr(db) (/+); He) spontaneously develop GDM and were compared to wild-type (WT) mice at day 18.5 of gestation. Uterine artery flow was assessed using ultrasound biomicroscopy. Uterine and mesenteric artery function was assessed using wire myography. Arterial superoxide production was measured using oxidative fluorescence microphotography. In vivo uteroplacental perfusion was impaired in mice with GDM, indicated by a significant increase in uterine artery resistance index. Maximal endothelium-dependent relaxation to methacholine was significantly impaired in mesenteric arteries from mice with GDM, while sensitivity was significantly reduced in uterine arteries. Both uterine and mesenteric arteries from mice with GDM exhibited a greater dependence on nitric oxide and increased superoxide production compared with those from mice with a healthy pregnancy. A significant source of superoxide in GDM mice was uncoupled nitric oxide synthase. These changes may contribute to the development of some of the fetal and maternal complication associated with GDM.

Objective: To estimate the utility of first-trimester 3D-placental volume and vascular flow indices in the prediction of adverse pregnancy outcomes., Methods: A prospective cohort study including women with singleton pregnancies seen between 11 and 14 weeks as part of a screening program for aneuploidy. Placental volume and vascularization indices were obtained using 3D power Doppler imaging and the VOCAL technique. Placental volume (PV), Vascularization Index (VI), Flow Index (FI) and Vascularization Flow Index (VFI) were calculated. The adverse pregnancy outcomes investigated include preeclampsia (PE), gestational hypertension (GH) and small for gestational age (SGA). The predictive ability of each variable was evaluated using receiver-operating characteristic (ROC) curves., Results: Of 388 women included, PE was seen in 30 (7.7%), GH in 37 (9.0%) and SGA in 31 (8.0%). Placental volume was not significantly different between the pregnancies with adverse outcomes and those without. The mean values of the VI and VFI were significantly lower in the pregnancies that developed PE but not in GH or SGA. The area under the ROC curve for the prediction of PE was 0.71, 0.69 and 0.70 for VI, FI and VFI, respectively., Conclusion: The study confirms lower 3D power Doppler vascular flow indices in pregnancies that develop PE. The discriminatory ability of using these indices alone for predicting PE appears modest., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Sonography is a fundamental tool in the management of pregnancies affected by maternal diabetes. Purposeful use of ultrasound in each trimester provides an invaluable amount of information about the developing fetus including gestational age and growth patterns, anatomical structure and function, assessment of fetal well-being, and prediction of adverse outcome. There are great ongoing research efforts in this field of prenatal diagnosis and management, yet even more are needed.